abstract: 'BackgroundThe continuing impetus for universal health coverage has given

  rise to publicly funded health insurance schemes in lower-middle income

  countries. However, there is insufficient understanding of how universal

  health coverage schemes impact gender equality and equity. This paper

  attempts to understand why utilization of a publicly funded health

  insurance scheme has been found to be lower among women compared to men

  in a southern Indian state. It aims to identify the gender barriers

  across various social institutions that thwart the policy objectives of

  providing financial protection and improved access to inpatient care for

  women.MethodsA qualitative study on the Chief Minister''s Comprehensive

  Health Insurance Scheme was carried out in urban and rural impoverished

  localities in Tamil Nadu, a southern state in India. Thirty-three women

  and 16 men who had a recent history of hospitalization and 14

  stakeholders were purposefully interviewed. Transcribed interviews were

  content analyzed based on Naila Kabeer''s Social Relations Framework

  using gender as an analytical category.ResultsWhile unpacking the

  navigation pathways of women to utilize publicly funded health insurance

  to access inpatient care, gender barriers are found operating at the

  household, community, and programmatic levels. Unpaid care work,

  financial dependence, mobility constraints, and gender norms emerged as

  the major gender-specific barriers arising from the household.

  Exclusions from insurance enrollment activities at the community level

  were mediated by a variety of social inequities. Market ideologies in

  insurance and health, combined with poor governance by State, resulted

  in out-of-pocket health expenditures, acute information asymmetry,

  selective availability of care, and poor acceptability. These gender

  barriers were found to be mediated by all four institutions-household,

  community, market, and State-resulting in lower utilization of the

  scheme by women.ConclusionsHealth policies which aim to provide

  financial protection and improve access to healthcare services need to

  address gender as a crucial social determinant. A gender-blind health

  insurance can not only leave many pre-existing gender barriers

  unaddressed but also accentuate others. This paper stresses that

  universal health coverage policy and programs need to have an explicit

  focus on gender and other social determinants to promote access and

  equity.'
affiliation: 'RamPrakash, R (Corresponding Author), Loyola Coll Campus, Loyola Inst
  Business Adm, Chennai 600034, Tamil Nadu, India.

  RamPrakash, Rajalakshmi, Loyola Coll Campus, Loyola Inst Business Adm, Chennai 600034,
  Tamil Nadu, India.

  Lingam, Lakshmi, Inst Social Sci, VN Purav Marg, Mumbai 400088, Maharashtra, India.'
article-number: '350'
author: RamPrakash, Rajalakshmi and Lingam, Lakshmi
author-email: rajalaksh@gmail.com
author_list:
- family: RamPrakash
  given: Rajalakshmi
- family: Lingam
  given: Lakshmi
da: '2023-09-28'
doi: 10.1186/s12889-021-10352-4
eissn: 1471-2458
files: []
journal: BMC PUBLIC HEALTH
keywords: 'Gender; Publicly funded health insurance (PFHI); Universal health

  coverage (UHC); Social relations (SR) framework; India; Gender analysis'
keywords-plus: EQUITY; CARE; INTERVIEWS; RESOURCE; GENDER; POLICY
language: English
month: FEB 12
number: '1'
number-of-cited-references: '61'
orcid-numbers: RamPrakash, Rajalakshmi/0000-0001-6785-5239
papis_id: 498cbe7b2661f28b04b0e121cbc752ee
ref: Ramprakash2021whyis
times-cited: '7'
title: 'Why is women''s utilization of a publicly funded health insurance low?: a
  qualitative study in Tamil Nadu, India'
type: Article
unique-id: WOS:000619749900006
usage-count-last-180-days: '2'
usage-count-since-2013: '6'
volume: '21'
web-of-science-categories: Public, Environmental \& Occupational Health
year: '2021'